A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?
Provide informational updates to members of the media.
Assist in discharging stable clients to home.
Delegate tasks to emergency health care specialists.
Determine the acuity and number of casualties arriving at the facility.
The Correct Answer is B
A. "Provide informational updates to members of the media" is incorrect. This task typically falls under the responsibility of the hospital’s public relations or communications team. Nurses do not usually handle media updates in the context of mass casualty events.
B. "Assist in discharging stable clients to home" is correct. During a mass casualty event, it is important to make room for incoming patients. Discharging stable patients helps free up beds and resources for those who need immediate care.
C. "Delegate tasks to emergency health care specialists" is incorrect. While nurses may delegate some tasks, the nurse’s primary responsibility in this scenario would be managing care within the medical-surgical unit, not directing emergency health care specialists.
D. "Determine the acuity and number of casualties arriving at the facility" is incorrect. This task is generally managed by triage teams or emergency management staff who assess incoming patients at the point of injury or arrival at the facility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.
B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.
C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.
D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.
Correct Answer is A
Explanation
A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.
B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.
C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.
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